HospitalInspections.org

Based on patient interview, staff interview and clinical record review the facility failed to include one of one hearing imparied patient (Patient #12) in participation of the development and implementation of his/her plan of care, when the facility failed to provide a sign language interpreter to be present during physician visits as well as evening group therapy sessions and failed to meet the patient's basic hygiene needs requests. The facility census was 55.
Findings include:
Interview with Patient #11 on 09/21/10 at 9:50 a.m. revealed: This patient stated that Patient #13 was being used at times, as a sign language interpreter in the evenings to assist in communication between facility staff and Patient #12 who was hearing impaired and unable to speak. Patient #11 states he/she heard Patient #13 tell the facility staff that if he/she was going to be used for a sign language interpreter than he/she wanted paid for it.
Interview with Patient #12 on 09/21/10 at 1:30 p.m. (with the assistance of a sign language interpreter) revealed: The patient had complaints of having communication issues due to not having a sign language interpreter in the evenings. The patient stated there were evening groups at 7 p.m., 8 p.m. and 9 p.m. that he could not attend due to not having a sign language interpreter in the evenings. The patient stated that he just sat in the day room and looked at magazines while the other patients were attending the evening groups. The patient also stated that his physician visits him every evening and he doesn't have a sign language interpreter during his physician visits and feels frustrated because he can't communicate with his physician as he would like. The patient stated the physician meets with the patient every evening for 30 minutes to 1 hour with the communication being writing notes back and forth between each other.
The patient stated that the facility won't let him shave as he has been on a suicide watch. The patient stated he had been at the facility since 09/15/10 which was six days and not been able to shave. This surveyor confirmed by observation that the patient had a beard growth and was unkempt. The patient stated other patients get to shave on suicide watch with the staff staying with the patients while the patients shave and the patient then giving the used razor back to the staff.
The patient also complained that the staff used another patient on the unit who knew sign language, to communicate with the patient during the evenings. The patient stated that he did not want another patient to be an interpreter.
The patient also complained he wore the same clothes (the clothes he had on at the time of admission) for 4 days and 4 nights while at the facility. He wore the same clothes at night because he had nothing else to sleep in. He stated he didn't want to sleep in his underwear because of girls walking by his room and he didn't want to be seen in just underwear. He stated he kept asking for some clean clothes and a shave and nothing was done. Finally two days ago the facility gave him a clean set of scrubs to wear and he had been in that set of scrubs now for 2 days and 2 nights. He stated he would like to shower, shave and put on some clean scrubs.
Review of the clinical record for Patient #12 revealed -
The patient's plan of care failed to include:
1) The need for a sign language interpreter for days, evenings and physician visits. The need for a sign language interpreter was absent in the plan of care;
3) The patient's need to shave and the type of shave the physician would allow such as electric shaver or safety razor and if the staff was required to monitor the patient while shaving;
Interview on 09/21/10, at approximately 4 p.m. with Director of Risk Management and Performance Improvement, registered nurse (RN), Employee E, revealed: This employee states that earlier today the facility had already determined that a sign language interpreter was needed in the evenings so Patient #12 could actively participate in evening group therapy and also have an interpreter present in the evenings during visits with the physician. It is confirmed from the patient's admission date of 09/15/10 through 09/21/10 the patient has not had an evening interpreter so he could attend evening group therapy and also confirmed the patient has not had an evening interpreter present for the evening physician visits.

Based on observation, interview and record review the facility failed to complete a thorough assessment of the need for the least restrictive, most appropriate device/restraint (a lap buddy-a vinyl covered piece of foam that wedges into the wheelchair in front of the patient so the patient cannot stand) prior to applying that device/restraint for two of three current patients (Patients #2, and #3) reviewed with restraints. The facility also failed to identify the lap buddy as a restraint; therefore, failed to obtain a physician ' s order for it, failed to continuously assess the need for it so it could be discontinued at the earliest possible time, and failed to address the lap buddy in the patients ' care plans. The facility census was 55.
Findings Included:
1. Review of a facility policy entitled, " Restraints; Seclusion; Protective Hold, " dated 06/22/10, revealed the following:
a) The facility limits the use of restraints to emergencies in which there is an imminent risk of a patient harming him/herself or others.
b) Restraints will only be used after less restrictive, non-physical measures have been attempted and have proven unsuccessful.
c) The application of a mechanical device restricting the free movement of the whole body, or a portion of the individual ' s body in order to control physical activity. The facility uses the following types of restraints-anklets, wristlets, and waist.
d) The goal is to discontinue restraints at the earliest possible time.
e) Attempts will be made to use the least restrictive device/method of controlling behaviors that may cause injury.
The facility could not provide a policy for the use of lap buddies, even though requested.
Review of Patient #2 ' s Admission Report Form, dated 09/18/10, revealed the patient was admitted on that day with a diagnosis of Alzheimer ' s disease with agitation.
Review of the patient ' s History and Physical (H & P), dated 09/19/10, revealed the patient was extremely confused, possibly alcohol-induced dementia. Diagnoses included alcohol abuse and delirium.
Review of the patient ' s Nursing Admission assessment, dated 09/18/10, revealed the patient had an unsteady gait and was weak. The patient had a history of congestive heart failure (according to assessment, this medical condition places the patient at a greater risk during restraint). The patient had no history of falls, but scored as a high fall risk on the assessment (15). The assessment recommended total care, fall precautions, and elopement precautions.
Review of a nurses ' note dated 09/19/10, timed 2:45 p.m., revealed the patient was in a wheelchair with a lap buddy on, frequently leaning forward in the wheelchair attempting to pick things up on floor. Oriented to name only.
Review of a nurses ' note dated 09/20/10, timed 2:45 p.m., revealed the patient was in a wheelchair with a lap buddy on. Again, the patient was not oriented.
Review of a nurses ' note dated 09/21/10, timed 12:50 a.m., revealed the patient was found on the floor, with the bed in a low position. The lap buddy was placed on the wheelchair. The note said the patient continued to be incoherent and tried to take the lap buddy off.
Review of the Master Treatment Plan revealed staff failed to identify the lap buddy as a restraint, and include goals and interventions regarding the use of the lap buddy.
Observation and interview on 09/21/10 at 10:31 a.m., revealed the following:
a) The patient was in a wheelchair with a lap buddy on.
b) The patient propelled him/herself with his/her feet.
c) The patient talked non-sensibly.
d) The patient could not remove the lap buddy when asked to (several times).
e) The patient could remove the lap buddy on occasion, but not with purpose.
f) The patient tried to stand, but could not because the lap buddy was in the way.
During an interview on 09/21/10 at 10:35 a.m., the DON said wheelchair alarms are not used on this unit, because the noise bothers the patients; however, they use bed alarms.
Observation on 09/21/10 at 1:05 p.m. revealed the patient sat in a wheelchair with the lap buddy on.
During an interview on 09/21/10 at 2:30 p.m., the Social Worker said this patient had been declared incompetent two years prior to admission. The patient sat in a wheelchair with the lap buddy on.
Observation on 09/22/10 at 8:52 a.m. revealed the sat in a wheelchair with the lap buddy on.
Observation on 09/22/10 at 9:07 a.m. revealed the sat in a wheelchair with the lap buddy on, even though he/she was in a group session with staff only three feet away at all times.
Facility staff failed to document assessment of the need for the least restrictive, most appropriate device/restraint prior to applying that device/restraint for patient #2. The facility also failed to identify the lap buddy as a restraint; therefore, failed to obtain a physician ' s order for it, failed to continuously assess the need for it so it could be discontinued at the earliest possible time, and failed to address the lap buddy in the patient ' s care plan.
Observation on 09/23/10 at 10:20 a.m. revealed the patient ambulating in the hallways with contact guard assistance of one staff. The patient ' s gait was slow, but steady.
2. Review of Patient #3's H & P dated 09/14/10 revealed the patient was admitted on 09/13/10 with a diagnosis of Alzheimer's dementia. The patient had been assaultive. The patient paced with a normal gait.
Review of the admission assessment dated 09/13/10 revealed the patient had a steady gait, paced constantly, had a history of seizures and high blood pressure (according to assessment, these medical conditions place the patient at a greater risk during restraint). The patient was considered a high fall risk.
Observation and interview on 09/21/10 at 12:52 p.m. revealed Patient #3 in a wheelchair with a lap buddy on. Mental Health Technician B said the patient had the lap buddy on because he/she wandered and hit others.
Review of Nurses' notes from 09/17-21/10 revealed the following:
a) The patient had the lap buddy on as early as 09/17/10. "In hall in gerichair lounger with lap buddy on for safety. Constant pushing at lap buddy."
Review of the Patient's record, and confirmed by by Registered Nurse D, staff failed to document an assessment identifying the lap buddy was the least restrictive, most appropriate device. Staff failed to document other methods attempted or continued assessment for possible release.
Review of the patient's care plan on 09/21/10, revealed staff failed to identify the lap buddy as a restraint or include goals and interventions regarding use of the lap buddy.